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December 2005 E-Newsletter

• The Step 2 Clinical Skills Exam: Just Another Hurdle
• 2006-2007 Council of Student Members (CSM) Call for Nominations
• Internal Medicine Interest Group of the Month: University of Rochester School of Medicine and Dentistry
• MKSAP Questions (1,2)
• MKSAP Answers (1,2)

The Step 2 Clinical Skills Exam: Just Another Hurdle

As you approach your fourth year of medical school, you begin to realize that medical school is all about conquering hurdles, whether they are basic science exams, shelf tests, or the different steps of the boards. Two years ago, the National Board of Medical Examiners (NBME) decided that medical students needed yet another hurdle to overcome, the Step 2 Clinical Skills (CS) Exam.

The Step 2 CS portion of the United States Medical Licensing Examination (USMLE) is designed to "assess the ability of examinees to apply medical knowledge, skills, and understanding of clinical science essential for the provision of patient care under supervision, and includes emphasis on health promotion and disease prevention." (1) The purpose of Step 2 CS is to determine how well a medical student or foreign medical graduate can collect information from a patient, perform physical exam skills, and communicate the information found in a medical record. These goals are accomplished through standardized patient-based examinations. The standardized patients are lay people trained to portray a clinical scenario. The cases demonstrated by the standardized patients are reviewed by practicing physicians and medical educators to ensure that they represent patients who would be seen in a current medical practice so as to reflect common symptoms and diagnoses. In order to ensure that all cases are distributed fairly and equitably across the country, the cases are based on an examination blueprint that is the same across the country on any given testing day. The examination is standardized so that the patients give the same information when they are asked the same or similar questions by different examinees.

The exam lasts approximately eight hours. Two breaks are given: the first is 30 minutes long for lunch and the second is 15 minutes long for a snack. The exam includes 11 or 12 patient encounters, a small number of which are not scored and are used for pilot-testing new cases. The testing area consists of a series of exam rooms equipped with standard exam tables, medical equipment, gloves, sinks, and paper towels. Outside each exam room is a cubicle with a computer where you will write your patient note after the encounter. Prior to entering the exam room, you will be able to review information posted on the exam room door giving the patient's name, age, gender, reason for visiting the doctor, and vital signs.

During your patient encounter, you will demonstrate a proficiency in focused history-taking and physical exam skills. From the information you gather, you will develop a preliminary list of differential diagnoses and studies that will help to clarify the diagnosis. These differentials and diagnostic tests should be explained to the standardized patient, and all of the patient's questions should be answered. You will have 15 minutes to complete the patient encounter. Remember that if you finish early and leave the exam room, you may not re-enter for any reason. If you do finish early, you may use the extra time to immediately begin writing your patient note.

Upon completion of each patient encounter, 10 minutes are allotted for you to complete a patient note. You may handwrite or type the note, whichever you are more comfortable doing. The note is a SOAP note similar to a clinic note that you would write in the medical record. You should record all pertinent history and physical exam findings, and you will be asked to list up to five differential diagnoses and up to five diagnostic tests that you would like to perform. Treatment, consultations, or referrals should not be included in the diagnostic work-up.

Step 2 CS is a pass/fail examination. The scoring is broken down into three subcategories:

1. Integrated Clinical Encounter: includes assessment of data gathering and documentation skills.

2. Communication and Interpersonal Skills: includes assessment of questioning skills, information-sharing skills, and professional manner and rapport.

3. Spoken English Proficiency: includes assessment of clarity of spoken English communication within the context of the doctor-patient encounter. All three subcategories must be passed successfully in order to pass the overall examination.

There are five testing sites throughout the United States, in Atlanta, Chicago, Houston, Los Angeles, and Philadelphia. Once you have picked the testing site and are ready to register for your examination, be aware that there are often two testing times available for any given testing day. The morning exam usually begins around 8:00 a.m. and ends around 4:00 p.m. and the afternoon exam usually begins around 3:00 p.m. and ends around 11:00 p.m. Please be cognizant of which time slot you are registering for. Travel guides providing information about each testing location are available online. This site provides information about travel and transportation, driving directions, parking and lodging information, and visitors' bureau links for the individual testing cities.

A few helpful hints for test day:

1. Get there a half an hour before your exam begins.

2. Luggage may not be stored at the testing centers.

3. Cubicles are provided for personal item storage during the test. However, these cubicles are not secured and cannot be accessed until the exam is over.

4. You only need to bring your lab coat and a stethoscope. All other medical equipment will be provided in the exam rooms. You will not be allowed to have personal pens, paper, medical equipment, electronic devices, etc., in the testing area.

5. There are no waiting facilities for spouses, family, or friends, so plan to meet them elsewhere after the exam is over.

6. The proctors will cover with adhesive tape or badges anything on your lab coat that identifies your institution.

7. Lunch and snacks will be provided for you.

8. Stay at a hotel very nearby the exam site the night before. Travel early and don't try to beat the traffic, because if you are late, you will not be allowed to enter the exam.

For additional information about the USMLE Step 2 CS Exam, please view the USMLE website. I highly recommend reading the "Step 2 CS Content Description and General Information" packet and watching the orientation videos that are available on the website. The Step 2 CS is not something to stress over, but it never hurts to know what the next hurdle entails before you are faced head-on with it.

Megan McCauley
CSM Representative, Southeastern Region
Mercer University School of Medicine, 2006
E-mail: mccauleymd@yahoo.com

Sources:

1. USMLE Step 2 Clinical Skills (CS) Content Description and General Information; www.usmle.org; copyright 2004 by the Federation of State Medical Boards of the United States, Inc., and the National Board of Medical Examiners (NBME).

2006-2007 Council of Student Members (CSM) Call for Nominations

For the 2006-2007 Council year, seven seats will be open. The seats that will need to be filled are:

Midwest Region (includes Arizona, Colorado, Kansas, Minnesota, Missouri, Nebraska, Nevada, North Dakota, South Dakota, Utah, and Wisconsin)

New England Region (includes Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont)

North Central Region (includes Michigan, Ohio, and Pennsylvania)

Osteopathic Representative (includes all Osteopathic schools)

Pacific Region (includes Alaska, California, Hawaii, Idaho, Montana, Oregon, Washington, and Wyoming)

Southeastern Region (includes Florida, Georgia, North Carolina, South Carolina, and Tennessee)

Southwestern Region (includes Alabama, Arkansas, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas)

Candidates may be self-nominated. Nominations will be accepted from ACP Medical Student Members who are in their first, second, or third year of medical school. Council members serve one to three year terms, depending on where they are in their medical school careers.

Council members are required to attend three meetings each year and participate in several conference calls throughout the year. CSM representatives are reimbursed for their travel expenses for these meetings and other Council-related expenses.

Candidates should submit a statement of candidacy, curriculum vitae, and one letter of recommendation by February 1, 2006. The CSM will conduct the elections during March and all candidates will be notified of the results by mail by March 15, 2006. More details about the nominations process and a sample nomination can be found on the Students, Residents, and Fellows-in-Training Home Page on ACP Online. Each candidate will be reviewed with neutrality to gender, race, and ethnic background.

Candidates should send their materials to:

Patty Moore
Medical Student Coordinator
ACP
190 N. Independence Mall West
Philadelphia, PA 19106
Fax: (215) 351-2708
E-mail: pmoore@acponline.org

Internal Medicine Interest Group of the Month: University of Rochester School of Medicine and Dentistry

The Internal Medicine Interest Group (IMIG) at the University of Rochester School of Medicine and Dentistry (URSMD) seeks to give medical students exposure to the world of internal medicine and its various subspecialties. This exposure comes in many forms, including monthly meetings highlighting each of the major medicine subspecialties, which facilitate the interaction of specialists with students who are interested in their fields.

The high level of interest in internal medicine at URSMD is well illustrated by the residency choices of last year's graduating class. Twenty two out of ninety-eight (22.4%) graduating medical students went into internal medicine, medicine/pediatrics, or an internal medicine subspecialty, some 3% higher than the national average.

The commitment of students to internal medicine is also evident in their participation in research within the field. Recently, Kofi Mensah, one of the co-coordinators of the IMIG, received first place in the Medical Student Poster Competition in the research category at the ACP Upstate New York Scientific Meeting for his research, "The Potential Role for IFN-alpha Therapy in Erosive Arthritis." At the same competition, fourth-year student Heather Huang won first place in the Public Policy & Advocacy Category (a combined Associate and medical student competition) for her work entitled, "Factors Affecting Mexican Migrant Workers' Health Care Choices in the U.S."

Members of the URSMD IMIG were integral in the planning of the school's annual Primary Care Week, which took place in mid-October. The event, overseen by the school's chapter of the American Medical Students Association, featured daily lunchtime lectures and discussions focusing on health literacy. The IMIG leadership team helped coordinate a well-attended interactive lecture about the specific health literacy needs of urban communities. The week was capped off by a Health Literacy Carnival at a local elementary school with which the medical school has ties. Again, IMIG leaders helped plan the event, and a cadre of members ran a successful booth that let the young students practice their baseball skills after answering questions regarding healthy diet, exercise, and lifestyle choices.

The coordinators of the IMIG seek to provide ACP Medical Student Members with high-quality lectures from the URSMD medicine faculty. The monthly lectures, by both primary care physicians and subspecialists, provide students with a taste of the breadth and diversity of specialties found in the medicine sphere. The topics are chosen to parallel areas of study within the basic science curriculum. This month we are featuring a lecture by a pulmonary and critical care specialist. We hope that this and future programs will allow students to integrate basic science material with the art of clinical medicine, in accordance with Rochester's biopsychosocial tradition.

Zachary Borus, Elton Lambert, Kofi Mensah, and Sydney Montesi
URSMD IMIG Co-Coordinators, Class of 2008
E-mail addresses: zachary_borus@urmc.rochester.edu, elton_lambert@urmc.rochester.edu, kofi_mensah@urmc.rochester.edu, sydney_montesi@urmc.rochester.edu

MKSAP Question 1

A 42-year-old man with asthma has low-grade fevers, productive coughing, and mild exertional dyspnea. He denies chest pain or hemoptysis. Six weeks ago a persistent cough had developed with sputum production. His temperature had been as high as 38.2 ºC (100.6 ºF), and he had expectorated thick brown cords in the phlegm. The patient was given a diagnosis of pneumonia and received a course of azithromycin without benefit.

The patient has had asthma since childhood. His only medications are inhaled fluticasone 440 µg a day and albuterol as needed. He does not smoke cigarettes but he does smoke marijuana.

The peripheral leukocyte count is 11,200/µL with 35% eosinophils. The chest radiograph shows diffuse pulmonary infiltrates.

What is the most likely diagnosis?

( A ) Mycoplasma pneumonia
( B ) Pneumococcal pneumonia
( C ) Allergic bronchopulmonary aspirgillosis
( D ) Tuberculosis
( E ) Psittacosis

MKSAP Question 2

A 46-year-old hospital janitor develops fevers, sweats, cough, and hemoptysis. He had been in generally good health, although he feels he may have lost about 6 pounds over the previous month. Six months earlier, his annual tuberculin skin test was negative. A chest radiograph now reveals a right upper lobe infiltrate with a small cavity.

Which of the following is the most appropriate management option?

( A ) Repeat the PPD skin test (5 tuberculin units)
( B ) Gastric fluid stains for acid fast bacilli
( C ) Perform a second strength PPD skin test (250 tuberculin units)
( D ) Bronchoscopy
( E ) Sputum stains for acid fast bacilli

MKSAP Answer 1

Answer: C

Educational Objective: Recognize allergic bronchopulmonary aspergillosis for a patient with asthma and pneumonia.

Several features in the clinical presentation raise the possibility of allergic bronchopulmonary aspergillosis (ABPA) as the cause of unresolved pneumonia. The patient has a subacute febrile illness with a cough productive of "cords" in the sputum (possibly representing bronchial casts). He has underlying asthma, and there are pulmonary infiltrates and profound peripheral blood eosinophilia. Use of marijuana increases the likelihood of inhalational exposure to Aspergillus organisms.

A number of diagnostic tests are helpful in establishing a diagnosis of ABPA. The total serum IgE level typically is very high, generally greater than 0.1 mg/dL (1.0 g/L) (normal value, 0.01 mg/dL [0.1 mg/L] or less). Allergy skin testing usually shows a positive immediate response to Aspergillus organisms, and sputum culture frequently grows Aspergillus organisms. Additional, useful serologic tests include identification of IgG antibody to Aspergillus organisms ("Aspergillus precipitins") and of IgE antibody specific for Aspergillus organisms at radioallergosorbent testing. An assay for Aspergillus antigen in the blood is not clinically available, and the results are likely to be negative among patients with ABPA.

Alternative diagnoses can be considered, including mycoplasma pneumonia (serum for cold agglutinins), psittacosis (antibody to Chlamydia psittaci), and tuberculosis (sputum for acid-fast bacilli). The first two types of pneumonia were appropriately managed with azithromycin. None of the three types is typically associated with peripheral blood eosinophilia. The peripheral blood eosinophilia is a clue that this patient does not have typical infectious pneumonia.

References

1. Cockrill BA, Hales CA. Allergic bronchopulmonary aspergillosis. Annu Rev Med. 1999;50:303-16.

MKSAP Answer 2

Answer: E

Educational Objective: Understand the relationship between tuberculin skin test and active tuberculosis.

Tuberculin skin testing is most valuable for assessing symptomatic or asymptomatic infection with Mycobacterium tuberculosis. A negative tuberculin skin test does not, however, exclude active tuberculosis. Negative tuberculin skin tests are found in approximately 20% to 25% of all adults with pulmonary tuberculosis. This does not include tests that are improperly performed (for example, with a subcutaneous injection of PPD tuberculin) or inaccurately read. Furthermore, there is a very real possibility of infection and progression to reactivation disease because the prior test was done 6 months earlier. The tuberculin skin test is more likely to be negative if the host is immunosuppressed. Second-strength skin testing (using more antigen in the Mantoux test) is seldom done because it tends to bring out more false-positive results and does not really make the diagnosis of active tuberculosis with any greater certainty.

In patients with cavitary tuberculosis, a reliable diagnosis can be made with expectorated sputum in most cases, thus sparing the patient the need for a bronchoscopy. In this man with classic symptoms and chest radiographic findings, sputum for acid-fast bacilli microscopy should be obtained on an emergent basis. A repeat PPD skin test is unlikely to clarify the issue and gastric acid stains for acid fast bacilli would be considered only if the patient could not produce sputum. Respiratory isolation in such a person is critical to limit nosocomial spread of tuberculosis.

References

1. Huebner RE, Schein MF, Bass JB Jr. The tuberculin skin test. Clin Infect Dis. 1993;17:968-75.

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